Comparison of Teleintegrated Care and Telereferral Care for Treating Complex Psychiatric Disorders in Primary Care A Pragmatic Randomized Comparative Effectiveness Trial
Comparison of Teleintegrated Care and Telereferral Care for Treating Complex Psychiatric Disorders in Primary Care A Pragmatic Randomized Comparative Effectiveness Trial
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DOI：
10.1001/jamapsychiatry.2021.2318
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发表时间：
2021-08-25
期刊：
影响因子：
25.8
通讯作者：
Unutzer, Jurgen
中科院分区：
文献类型：
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作者：
Fortney, John C.;Bauer, Amy M.;Unutzer, Jurgen
只有三分之一的复杂精神疾病患者接受专业精神卫生保健，只有十分之一的患者在初级保健中接受充分的治疗。可扩展的方法是迫切需要改善获得有效的心理健康治疗在服务不足的初级保健settings. ObjectiveTo比较两个诊所到诊所的互动视频方法，提供循证心理健康治疗的患者在初级保健clinics.Design，设置，和参与者这一务实的比较有效性试验使用了一个顺序，多分配，随机试验（SMART）设计，患者水平随机化。2016年11月16日至2019年6月30日，招募了在24家初级保健诊所接受治疗的成年患者，这些患者来自3个州的12个联邦合格的健康中心，他们对创伤后应激障碍和/或双相情感障碍筛查呈阳性，并且尚未接受心理健康专家的药物治疗。干预两种方法进行了比较：（1）远程精神病学/远程心理学增强转诊（TER），其中远程精神科医生和远程心理学家承担治疗的责任，和（2）远程精神病学协作护理（TCC），其中远程精神科医生提供咨询的初级保健团队。TER包括一个适应性干预（电话增强转介[PER]）的患者不参与治疗，其中涉及电话外展和动机interviewing.Main结果和措施调查问题评估患者报告的结果。退伍军人兰德12项健康调查精神成分总结（MCS）评分是主要结局（范围，0-100）。次要结果包括创伤后应激障碍症状，躁狂症状，抑郁症状，焦虑症状，恢复和不良反应。结果1004名参与者中，701/1000（70.1%）为女性，660/994（66.4%）为白色，平均（SD）年龄为39.4（12.9）岁。基线MCS评分比美国平均值低2个SD; TCC和TER组的平均（SD）MCS评分分别为39.7（14.1）和41.2（14.2）。接受TCC和TER的患者12个月MCS评分无显著差异（β = 1.0; 95% CI，-0.8至2.8; P = 0.28）。两组患者从基线至12个月均出现了较大且具有临床意义的改善（TCC：Cohen d = 0.81; 95% CI，0.67 - 0.95; TER：Cohen d = 0.90; 95% CI，0.76 - 1.04）。对于6个月时未进行TER的患者，接受PER和TER的患者12个月MCS评分无显著差异（β = 2.0; 95% CI，-1.7至5.7; P = .29）。结论和相关性在这项复杂精神障碍患者随机接受TCC或TER的比较有效性试验中，在两组中均观察到显著和实质性改善的结果。从医疗保健系统的角度来看，临床领导应该实施最可持续的方法。
IMPORTANCE Only one-third of patients with complex psychiatric disorders engage in specialty mental health care, and only one-tenth receive adequate treatment in primary care. Scalable approaches are critically needed to improve access to effective mental health treatments in underserved primary care settings.OBJECTIVE To compare 2 clinic-to-clinic interactive video approaches to delivering evidence-based mental health treatments to patients in primary care clinics.DESIGN, SETTING, AND PARTICIPANTS This pragmatic comparative effectiveness trial used a sequential, multiple-assignment, randomized trial (SMART) design with patient-level randomization. Adult patients treated at 24 primary care clinics without on-site psychiatrists or psychologists from 12 federally qualified health centers in 3 states who screened positive for posttraumatic stress disorder and/or bipolar disorder and who were not already receiving pharmacotherapy from a mental health specialist were recruited from November 16, 2016, to June 30, 2019, and observed for 12 months.INTERVENTIONS Two approaches were compared: (1) telepsychiatry/telepsychology-enhanced referral (TER), where telepsychiatrists and telepsychologists assumed responsibility for treatment, and (2) telepsychiatry collaborative care (TCC), where telepsychiatrists provided consultation to the primary care team. TER included an adaptive intervention (phone-enhanced referral [PER]) for patients not engaging in treatment, which involved telephone outreach and motivational interviewing.MAIN OUTCOMES AND MEASURES Survey questions assessed patient-reported outcomes. The Veterans RAND 12-item Health Survey Mental Component Summary (MCS) score was the primary outcome (range, 0-100). Secondary outcomes included posttraumatic stress disorder symptoms, manic symptoms, depressive symptoms, anxiety symptoms, recovery, and adverse effects.RESULTS Of 1004 included participants, 701 of 1000 (70.1%) were female, 660 of 994 (66.4%) were White, and the mean (SD) age was 39.4 (12.9) years. Baseline MCS scores were 2 SDs below the US mean; the mean (SD) MCS scores were 39.7 (14.1) and 41.2 (14.2) in the TCC and TER groups, respectively. There was no significant difference in 12-month MCS score between those receiving TCC and TER (beta = 1.0; 95% CI, -0.8 to 2.8; P = .28). Patients in both groups experienced large and clinically meaningful improvements from baseline to 12 months (TCC: Cohen d = 0.81; 95% CI, 0.67 to 0.95; TER: Cohen d = 0.90; 95% CI, 0.76 to 1.04). For patients not engaging in TER at 6 months, there was no significant difference in 12-month MCS score between those receiving PER and TER (beta = 2.0; 95% CI, -1.7 to 5.7; P = .29).CONCLUSIONS AND RELEVANCE In this comparative effectiveness trial of patients with complex psychiatric disorders randomized to receive TCC or TER, significantly and substantially improved outcomes were observed in both groups. From a health care system perspective, clinical leadership should implement whichever approach is most sustainable.